1. 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study
Fibroids Ch 20
Academic Year
MSIII Ob/Gyn Clerkship
Self-Directed Study
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

2. Clerkship Self Directed Studies
Case Study
41 yo G3P3 AAF presents to clinic with c/o abdominal bloating, pelvic pain, and pressure. C/o feeling her uterus through her abdomen as if she was pregnant, but she had a BTL 8 yrs ago. Menses are q28days with heavy bleeding and large clots, lasting 9 days. Exam reveals a 14-week irregular shape, mobile uterus and normal adnexa bilaterally.
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

3. Clerkship Self Directed Studies
Questions to Consider
1. What is your differential diagnosis?
Uterine  Fibroids, adenomyosis, Endometrial cancer
Adnexal  Ovarian cancer, ovarian cyst
Abdominal  Colon tumor, intestine etiology
2. What are treatment options for women with fibroids?
Hormonal therapy (OCPs, Progesterone, GnRH Agonists)
Myomectomy (hysteroscopic, laparoscopic, abdominal)
Hysterectomy
Uterine Artery (Fibroid) Embolization (UAE/UFE)
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

4. Clerkship Self Directed Studies
3. If she was a 22 yo G0P0 how would your recommendations change?
Uterine conservation therapy (fertility desires)
4. What makes fibroids get bigger? Smaller?
Estrogen, progesterone, Pregnancy Menopause
5. What are risk factors for fibroids?
Increasing age, African Am, nulliparity, FMHx
6. How often can fibroids become malignant?
Less than 1 per 1000 uteri
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

5. APGO Educational Topic 53
A. Describe the prevalence of uterine leiomyomas.
B. Describe the symptoms and physical findings in patients with uterine leiomyomas.
C. Apply diagnostic methods to confirm uterine leiomyomas.
D. List the indications for medical and surgical treatment of uterine leiomyomas.
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

6. Clerkship Self Directed Studies
Prevalence
45% of women have fibroids by age 50
Many are asymptomatic
Primary indication for hysterectomy
200,000 – 300,000 surgeries per year in USA
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

7. Clerkship Self Directed Studies
Symptoms
Menorrhagia, metrorrhagia, menometrorrhagia  anemia
Pelvic mass
Pelvic pressure
Bloating (clothes fit tighter)
Feeling of heaviness
Low Back Pain
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

8. Clerkship Self Directed Studies
Signs (Physical Exam)
Abdominal palpation – uterus palpable if larger than 14 week size (correlate size of uterus to gestational sizing)
Irregularly shaped uterus on BME, masses move with cervix
Nodular uterus (firm, cystic, soft)
Recto-vaginal exam – can palpate posterior fibroids
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

9. Clerkship Self Directed Studies
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

10. Clerkship Self Directed Studies
Diagnosis
History and Physical Exam !!!!!!!!!!!
Endometrial biopsy
Rule out endometrial cancer
Ultrasound
Can usually identify fibroids on US – will NOT r/o leiomyosarcoma (malignant fibroids)
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

11. Clerkship Self Directed Studies
US Images of fibroids
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

12. Treatment When to Operate and When to Wait?
Conservative Treatment
Desired fertility
Declines operative Tx
Correct anemia prior to surgery
Poor surgical candidate
Postmenopausal (depending on sx’s)
Hysterectomy
Premenopausal
No future fertility desires
Large uterus (>12-14 week size)
Could consider myomectomy if fertility
Concern for cancer
Renal obstruction
Medical Tx is sometimes first line, followed
by surgical Tx for medical Tx failures.
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies

13. Clerkship Self Directed Studies
Treatment Options
Cannot achieve pregnancy during this Tx
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies